Experience of local self-governments in providing medical services to the population in developing and developed countries

INTRODUCTION

As you know, human health, life and safety are paramount in all countries.

First of all, the main concern of the state is the health of the population. In many countries, local self-government and governance play a major role in this regard.

Local self-government is a system of public relations recognized and guaranteed by law, related to the self-organization of the population, within the territorial unit, under its own responsibility, independently of the central public authority, manages matters of local importance through democratically based local authorities taking into account the interests of the local population.

Self-government means the regulation of public affairs by members of society, independently and under their own responsibility. It is the self-organization of citizens to jointly resolve issues of common interest to them. The main subject of self-government is the population.

The exercise of the right of self-government by citizens begins with participation in local self-government elections and continues with the involvement of bodies elected by them in solving local problems. Citizen participation is the main guarantee of self-government independence. Also, the more citizens are involved in the implementation of self-government, the higher the quality.¹

As is well known, the basic tenets of the state theory of self-government were developed by nineteenth-century German scientists Stein and Gnaits, who considered: self-government as one of the forms of organizing local state governance; local self-government powers as derived from state authorities according to their source; local self-government is exercised by local residents interested in the results of local government and not by government officials appointed by the central government; issues decided by local self-government bodies are of the same nature as state issues; the transfer of individual issues by the state to local self-government for resolution serves the purpose of their more effective resolution at the local level.

Stein et al Gnaits’s differing views on the definition of the hallmarks of local self-government later became the basis for the formation of two currents of the theory of state self-government- the political (Gnaits) and the legal (Stein).¹

Financial resources are essential for local government

Local finance, as the main economic lever of local self-government bodies, is one of the most important parts of the financial system of states.² Their role and importance are gradually growing in the wake of the development and integration of the world economy.

Through local finances, local governments distribute, redistribute and use national income in accordance with the social, economic and other functions assigned to them.³

Through local finances, local governments distribute, redistribute and use national income in accordance with the social, economic and other functions assigned to them. The process of decentralization of the economy is underway, where local finances are increasingly involved in the regulation of the economy, the area of their use is growing and expanding in the implementation of socio-economic development and regional targeted programs, in the production of labour again, and so on.^2,4

Perhaps you are wondering what is local government?

Local government is a system of locally elected members representing their communities and making decisions on their behalf, and self-government is the right and opportunity of the citizens living in the territory of the local self-government unit, through local self-government bodies elected by them, to resolve issues of local importance.⁵

In 1921, with the loss of Georgian sovereignty, the normal development of constitutional and legal processes in Georgia ceased, which again became relevant in 1993-1995, during the work of the State Constitutional Commission.

On October 26, 2004, the European Charter of Local Self-Government was ratified (Strasbourg, 15.10.1985); which entered into force for Georgia on April 1, 2005. It, as an international treaty, has the supreme legal force over the legislative acts of Georgia.

The Charter, if possible, considers it desirable to be regulated by the constitution of the local self-government. The constitutional strengthening of the principle of self-government gives it even more “weight” and importance among public authorities.

As a result of the constitutional reform of 2009-2010, the constitutional-legal foundations of local self-government were strengthened. A separate, seventh prima facie chapter has been established in the constitution. The constitution stipulates that powers are separated between the self-government and the state; the principle of material compensation applies to the exercise of delegated powers; in case of abolition of the self-governing unit or change of borders, it is obligatory to consult with this unit; the self-governing body is accountable to the representative body, the self-government has the right to appeal to the constitutional court.³

As for the municipality, there is a theory of dualism and now I will tell you what a double character means.

The dual nature of municipal activities (independence in local affairs and the performance of separate state functions at the local level) underlies the theory of dualism of municipal government. This theory argues that if municipal bodies go beyond local interests in the exercise of their governing functions, then they should be considered and act as a tool of state administration.

Social service theory

The social service theory was developed by another science, which focuses on the fulfilment of one of their main tasks by the municipalities, offering services to the population, organizing services for the population of the municipality. According to this theory, the main goal of municipal activities is the welfare of the commune residents.¹

The local budget is the main financial, balance plan of the expenses for the fulfilment of the budget revenues and obligations of the municipality, which is approved by the local self-government representative body (city council).

States actively pursue national policies through local finances. The key elements of local finance are: local budgets, special purpose local funds (budgetary and non-budgetary), finances of enterprises owned or managed by local self-government bodies.⁵

Every municipality in Georgia has its own independent budget.

It is within the competence of the public health service: a) infection, reporting, data analysis and forecasting of infectious and non-infectious diseases; b) epidemiological surveillance and epidemiological control; c) provide appropriate information to health services and the population, provide recommendations and prepare recommendations on the causes, spread and control of infectious diseases; d) planning measures to limit or eliminate the spread of communicable diseases; e) planning measures to ensure safe blood supply; f) prevention of non-communicable diseases; g) promoting a healthy lifestyle; h) promoting a safe environment for human health.⁴

The right to health, indicators and standards belong to the WHO Charter (1946), “enjoying the highest attainable standard of health is one of the fundamental rights of every human being”.

Understanding health as a human right imposes a legal obligation on the state, ensure access to adequate quality of timely, acceptable and affordable healthcare, as well as relevant health determinants such as safe drinking water, sanitation, food, health-related housing. Information and health education and gender equality.

States’ obligation to protect the right to health- including “maximum resources available” in order to achieve this goal gradually- it is considered through various international human rights mechanisms, such as the universal periodic review or the economic, social and cultural committee. Rights- in many cases, the right to health is enshrined in national law or the constitution.

A human rights-based approach to health requires, that health policies and programs prioritize the needs of people who are at the forefront of greater equality.

The right to health must be exercised without discrimination on the basis of race, age, ethnicity or any other condition. Despite respect for the principles of discrimination and equality, states should take steps to remedy any discriminatory laws, practices and policies.

Another characteristic of human rights-based approaches is constructive participation. This means that national stakeholders, including non-governmental actors, such as NGOs, are constructively involved in the development of programs at all stages- evaluation, analysis, planning, implementation, monitoring and analytical reporting.^6,14

Human rights violations in healthcare

Human rights are interconnected, inseparable and interdependent. This means that violating one person's health rights may harm another person's health rights.⁷

Violation or neglect of human rights can have serious health consequences. Explicit or implicit discrimination in health care- both between health care workers and health care workers and service users- is a strong barrier to accessing health care services and affects their quality.⁸

Mental disorder often leads to attacks on human dignity and independence; including involuntary treatment or institutionalization and neglect of the decision-making subject. Paradoxically, public health continues to neglect mental health through violence, poverty, and despite social exclusion, which contributes to the deteriorating mental and physical health outcomes of people with mental disorders.⁸

Violations of human rights not only aggravate the health condition of many people, including people with disabilities, HIV-infected women, sex workers, drug users, transgender and intersex people, health facilities are places where they can put people at increased risk, violation of rights, including involuntary treatment or procedures.⁸

The right to health covers a wide range of socio-economic factors, which creates the conditions for people to lead a healthy lifestyle, and its main components are: health care such as food and diet, normal living conditions, access to drinking water and adequate sanitation; safe and harmless working conditions and a favourable human health environment; with a human rights-based approach, it is essential to plan an effective strategy regarding the health of particularly stigmatized individuals.⁹

Let us now consider the different countries.

Local governments in the UK are very different from each other and it all lies in the following: for example, if in England, Scotland and Wales the councils are responsible for social care and provide transport, in some aspects of housing and education, they are also responsible for a number of neighbourhood services, including libraries and waste collection, local government is more limited in Northern Ireland. Councils provide neighbourhood services such as garbage collection and street cleaning. However, they are not responsible for education, libraries or even social care.¹⁰

It is also interesting how local councillors are elected.

In England, for example, councillors are elected once every four years under the following conditions for single or multi-member chambers, using the first post-election system. Board seats are elected once every four years. In 68% of the councils, one third of the elected councillors are elected within three years, 30% of every four councils every 4 years and about 2% halve every two years.¹¹

In Scotland, councillors are elected by a single vote in multi-member chambers, with a proportional voting system that allows voters to rank candidates. Councils usually elect integrity once every four years. In 2015, the Scottish Parliament expanded franchising in local elections for 16- and 17-year-olds.

In Wales, advisers are elected by holding their first post in single and multi-member chambers, and councils hold elections every four years. Senad Simru (Parliament of Wales) recently voted to expand the local franchise- just like in Scotland- to young people aged 16 and 17.

In Northern Ireland, councillors are elected in multiple polling stations by a single ballot. All advisors are elected once every four years.¹²

Germany is a democratic and social state based on the rule of law. Here is a two-tier model of governance where the interests of the residents come first. The state structure is regulated by the basic law of Germany.¹³ Where the community has the opportunity to resolve its problems independently within the law under its responsibility. Modern France is a so-called continental model of local self-government, and also one of the countries with four levels of government: communal, departmental, regional and national, where this principle of operation of the continental model is reinforced by the European Charter of Local Self-Government.⁶

METHODS

The research was conducted throughout Georgia, in the capital and major cities: Tbilisi, Batumi, Kutaisi, Dusheti, Telavi, Gori, Zugdidi. The study population consisted of adults, one of the main conditions was the mentioned issue.

The study design was a selective type, which implemented from April 20, 2021 to October 20, 2021.

Inclusion criteria

Inclusion criteria was adult people who lived in the main cities of the country.

Our study did not require an ethical approval because the study was completely confidential and the Bioethics Board approved the above questionnaire and issue from the beginning.

Study procedure

The completed form of the study was electronic, the first page included information about the study and also consent from the person who agreed to be involved in the study, and attention was paid first to age and then to be a resident of a large city Tbilisi, Batumi, Kutaisi, Dusheti, Telavi, Gori, Zugdidi. A resident could not participate if he was not a resident of a large city and also if he was not of legal age.

Statistical method and tool

We conducted a survey of 1,010 people across Georgia, where the survey showed the real situation of the population, their attitude towards the health of the living environment, as well as the role of local government and self-government and to make recommendations to the relevant service. We found out with a questionnaire why the population applied to the city hall and the board, what problems they faced, what and how much they helped and what they changed. Through research, we were able to see what is bothering the population, solve problems, develop programs and improve local government and self-government services, change the environment and increase funding for them.

Why we conducted and selected this particular study

We did it, because the survey is very relevant today, because there is a very large number of people applying to both the city hall and the municipality, and our desire was to assess how healthy the population perceives the environment in which they live.

The purpose of the survey was to survey the population over the age of 18, no such survey has been conducted by others, so we have found relevant information abroad. The aim of the research was to identify the shortcomings and find ways to solve them. The research was done using google form, we observed the numbers, we studied their problems, the data was stored in Excel, where we processed and re-analyzed. The research was managed by us.

This required the help of others, especially in the regions, and required time and resources. The plan was written for the period before the 1011 respondents were collected, which we managed to do in a six month. It is ethically acceptable and does not need to be discussed ethically as the information is completely confidential. The research was very interesting, we could not generalize this research with other studies conducted in Georgia, because a similar type of research was not conducted.

The criteria for inclusion in the study was

Age of population

The age of the respondents was over 18 years and the total number was 1010 inhabitants.

Consent to participate in the study

Only one person refused to participate in the study.

Having insurance

100% of respondents (1010 inhabitants) have insurance, both universal and private insurance.

Cities

The research was conducted throughout Georgia, in the capital and major cities: Tbilisi, Batumi, Kutaisi, Dusheti, Telavi, Gori, Zugdidi.

Employment

Most of the interviewees (except for the elderly) were employed both in private companies and self-employed.

Exclusion criteria

Exclusion criteria from the study were: no insurance; the survey was conducted among the citizens of the country, where all residents were insured; population under 18 years of age.

The survey directly indicated age and everyone had to be of legal age because adult citizens can come and avail the services and also they would tell us complete information about funding.

RESULTS

These issues became more apparent when we conducted a survey of 1,010 people across Georgia, the purpose of the survey was to assess the population’s opinion, their attitude towards funding, as well as their opinion on the role of local government and self-government. The questions in the questionnaire were about the state of the environment, its protection, health care and the quality of services received with them. Through the research we will be able to see what problems the population is going through in the city hall and the board, solve problems, work out solutions and improve local government and self-government services, change funding issues and increase funding for them.

Why we conducted and selected this particular study

We did it, because the survey is very relevant today, because there is a very large number of people applying to both the city hall and the municipality, and our desire was to assess how healthy the population perceives the environment in which they live.

The purpose of the survey was to survey the population over the age of 18, no such survey has been conducted by others, so we have found relevant information abroad. The aim of the research was to identify the shortcomings and find ways to solve them. The research was done using google form, we observed the numbers, we studied their problems, the data was stored in Excel, where we processed and re-analyzed. The research was managed by us.

The survey was confidential, inclusion criteria were determined by demographic characteristics, surveyed the population above 18 years of age and were also characterized by geographical characteristics. The survey allowed us to draw enough points to make the survey representative, the survey did not require ethical review because the questionnaire was confidential because the information or data used did not allow the individual to be identified.

This required the help of others, especially in the regions, and required time and resources. The plan was written for the period before the 1011 respondents were collected, which we managed to do in a month and a half. The study was very interesting, we could not generalize this study with other studies conducted in Georgia, because we have not had a similar type of research.

Consent to participate in the study

1,011 population age above 18 years were included in the group. One of these respondents refused the survey.

Age

These age groups were combined into 4 age groups (Table 2). 294 of them were people aged 18 to 25 years, 534 were persons aged 26 to 50 years, 133 were persons aged 51 to 70 years, 49 were persons above 71.

Population from different cities

Most of the respondents were from big cities (Figure 1).

DISCUSSION

The mentioned research, which we conducted, has not been conducted across the country. At first we imagined that many people would not take part in the study especially after covid and so much stress, but the study conducted in 6 months and 1010 respondents it was amazing. Only 1 respondent refused. As we thought there would be many self-employed people, people who do not know that they have insurance, as well as people who did not turn to the city hall and the board for help, but fortunately this was not the case. They applied for suburbs, housing, squares, and most importantly for health, medicine and aftercare funding. 75% of respondents received full funding, the rest received at least half of the funding. This study was not conducted in my country. Of the 1010 respondents, we thought that half were not officially employed (583 citizens), and none of them knew about their insurance (everyone had 100% insurance) only considering that the self-government and the manager only refer to the following for health reasons: surgery, medicines, oncology, but they also refer to squares, due to the roof of the building.

CONCLUSION

The study found that 583 out of 1010 people were employed, 3 were self-employed, which indicates the poverty and misery of the population, of which 734 citizens have higher education, but this is not a guarantee that they will be employed accordingly; 664 people enjoyed universal insurance, which indicates that they are not properly employed, because if a person is employed in a normal job he will have valuable insurance; 647 out of 1010 respondents were satisfied with the satisfaction of the MP and the municipality, 184 of the respondents stated that they applied for help to the city hall and the board, 723 stated that they did not apply and 93 do not remember about it.

We also interviewed how many times 107 respondents applied for help once, 40 twice, 16 three times and 21 four times. 17 of the respondents mentioned that they applied because of utility problems, 26 because of environmental problems, 52 because of operation financing, 20 for financing medicines, 3 for financing education, 3 for property problems, 57 for other financial problems. With problems and 9 did not remember the reason he applied to city hall and board. Of the respondents who refused funding, we wondered if they received a complete answer, 52 of the respondents said they provided complete information, 35 said that the answer was incomplete, 16 said that they did not provide the relevant information at all and 81 of the respondents did not have it, a similar case. 194 out of 1010 respondents applied to the city hall and the board for assistance. Most of them 107 respondents mentioned that it took 1 day to solve the problem and also 41 people did not need to collect any documentation. A total of 72 people applied for health problems, the largest number of which were oncology and cardiovascular problems. 81 people did not refuse help, but those who refused 50 customers gave a perfect answer. Those of the respondents who needed help and did not apply for help from the city hall and the board, wondered what was the reason why they refrained. 106 of the respondents did not have such a case, 72 did not apply because they had no hope, and 6 of them refrained and did not apply. 131 of the respondents addressed the following problem 20 of them with oncological problems, 6 with endocrinological diseases, 14 with diseases of the cardiovascular system, 43 did not name the cause of health and the remaining 48 respondents applied for other reasons. 134 of the respondents mentioned that they finally got the help they needed, the respondents wanted to increase the number of staff, improve e-services, be charming and help people more. 117 of the respondents want to increase funding for health services and 45 want to increase funding for one-time assistance.

In Georgia, it would be good to conduct a survey, for a certain period of time, both on site and online and be confidential. Find appropriate resources (financial, human) for training and further supportive supervision. The purpose of the submitted proposals and recommendations is to improve the issue of services and to make the problems of the population understandable and to find ways to solve them. Make changes in the legal acts, which will empower the staff of the city hall and the board to carry out ancillary supervision for the relevant entities, which will allow not only the performance of work, but also on-site training, which will improve the professional skills of staff. It is important to note that deficiencies identified during auxiliary supervision do not imply further administrative punishment.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by The Tbilisi State Medical University

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